Assessment Findings. Assessment Criteria

Transcription

1 Rule 225: RN Delegation & Tasks Not Requiring RN Delegation in Independent Living Environments with Stable & Predictable Condition Professional Nursing Assessment Grid Instructions: Choose the description that most closely matches the RN assessment of the criteria [Rule 225.6(b)]. Place the corresponding score (numbers -4 or 5) in the grid for that client. Add all scores vertically to arrive at a total score for a given client. There are a total of 25 points possible. Assessment Criteria Assessment Findings *CRA= s Responsible Adult A B C D Ability of client or CRA* to participate in health care decisions and to direct and manage the performance of the task ) with high cognitive functioning or CRA very willing & able to be involved in care decisions 2) with moderate cognitive functioning or CRA only willing and able to assist with certain aspects of care decisions 3) with low cognitive functioning or CRA s ability or willingness to assist with care decisions limited 4) is comatose or cognitively incompetent, or CRA never willing or unable to help with care decisions [if both client and CRA unable to participate, cannot delegate under Rule 225 and must use Rule 224, see Rule 225.(a)(2)] Adequacy/ reliability of support systems available to client or CRA ) Family/friends/other always available if needed & able to assist with care 2) Family/friends/other available approximately 50% of the time or ability to assist is limited 3) Family/friends/other available on occasion, but not on a regular/predictable basis; or ability to assist minimal for whatever reason 4) No support system of any kind available Degree of stability and predictability of client s health status relative to the task(s) to be delegated or exempted s condition relative to task to be performed by unlicensed person is: ) Extremely stable and predictable 2) Stable and predictable 90% of time 3) Stable and predictable 75% of the time 4) Rarely (<25%) stable & predictable 5) Never stable and predictable [then cannot delegate under Rule 225 and must use Rule 224, see Rule 225.(a)(3)]

2 Knowledge base of client or CRA regarding client s health status Ability of client or CRA to communicate in traditional or non-traditional methods **How frequently will the client s status be re-assessed? ) /CRA: Very knowledgeable about health and disease processes impacting client, and can direct UAP for all tasks. 2) /CRA: Knowledgeable to direct care on most of client s tasks. 3) /CRA: Limited knowledge of how to direct tasks. 4) /CRA: No knowledge of client s condition and/or tasks to be performed (cannot exempt ADLs/HMAs from delegation if neither the client nor the CRA has this knowledge base) ) No language barriers 2) Either UAP or client/cra has limited command of English, or client has mild aphasia, has mentally retardation, etc. 3) Communication factors create a significant barrier but both UAP & client/cra willing and able to work on adapting to situation 4) Profound communication barriers (no common language, severe cognitive impairment or total aphasia, etc.) ) Re-assess between 6 months- year 2) Re-assess every 90 days 3) Re-assess monthly or bi-monthly 4) Re-assess every week or more often Total Score Score each criteria by its corresponding number; ie: high cognitive function =, comatose = 4 **Regulations for specific settings may dictate re-assessment time frames that differ from this example. Adapt the assessment finding definitions to correlate with the applicable regulations. Suggestions for Use: A low overall score would indicate that the activity/task could be safely delegated or exempted (not requiring delegation). A mid-range score would caution against exemption, but based on RN judgment and assessment, might be safe to delegate. A high score would caution against exemption and delegation, but strength in some criteria could off-set weaknesses in other criteria. For example, delegation with increased supervision or a highly-experienced and competent UAP may make the RN s decision to delegate safe and prudent. Remember: Nursing Tasks cannot be exempted from delegation. 2

3 Rule 225: RN Delegation & Tasks Not Requiring RN Delegation In Independent Living Environments w/stable & Predictable Condition Case Examples These examples utilize the Assessment Criteria in 225.6(b) in a grid-scoring format to assist the RN in determining tasks that are either safe to delegate or to exempt from delegation. The rules must be applied in their entirety to actual client/patient situations where the RN is considering delegation or exemption from delegation. CLIENT A: The client is a 25 y/o home vented patient with severe Multiple Sclerosis, bedbound, unable to direct his own care but a parent is available 24/7 either in home or telephonically and never more than 30 minutes from home; the parent is very willing to participate in care decisions. The unlicensed assistive person (UAP) has been with this client for 2 years and is very mature/reliable in carrying out activities of daily living (ADLs) and health maintenance activities (HMAs), as well as certain delegated nursing tasks (including trach care and suctioning). All ADL/HMA tasks have previously been exempted from delegation by the RN. Up until now, the Home Health RN has been making routine visits every 90 days, and as needed to reassess if there are any changes in the client s condition. This client developed an obstruction of his G-tube, which required an overnight hospital stay for placement of a new G-tube. At home again, his vital signs are stable, and the RN assesses his condition to be stable and non-fluctuating (ie: no change from his previous condition). Decision: Score = 9 (out of 25 possible). Based on RN assessment, it is acceptable to continue exemption of ADLs and HMAs. The client s condition is stable and the UAP is capable of safely completing tasks related to the client s change in condition. The RN elects to make skilled RN visits every two weeks for the first month to assess the status of the new G-tube and client s status in general to be sure the client s status remains non-fluctuating. Notes: 3

4 CLIENT B: The client is a 70 y/o male, Wt. 50kg. He was admitted to an assisted living facility (ALF) from a rehab hospital today following a cerebral vascular accident (CVA) which left him with right-sided paralysis of his arm and leg, and moderate expressive aphasia. While in the hospital, the client fell and broke his hip on the affected (right) side; surgical correction was done two weeks ago. The ALF provides 24-hour UAPs. In working through the assessment criteria [Rule 225.6(b)], the RN discovers that the UAP assigned to the client on day shift (7A-7P) has 2 months of experience since completing home health aide training, and has never cared for a CVA client. This UAP is a 60kg female. The task being considered for delegation or exemption is transferring the client (bed-to-chair, chair-to-toilet, etc.) The RN further assesses that the client s wife (who is his CRA), is elderly and physically frail, and has also moved into the ALF in the same room as her husband. She has served as his responsible adult for health care decisions since his stroke. While she is willing to participate in care decisions, she lacks the knowledge base to direct the UAP in ADL or HMA tasks for the level of care her husband currently requires, and she is physically unable to be of any assistance. Decision: Score = 5.5 (out of 25 possible). The RN determines it will be necessary, at least initially, to delegate the ADL task of transferring, and that she will directly supervise this task at least the first few times, as both the experience of the UAP and the ability of the CRA to direct the task are too limited to make the task safe for exemption. The RN determines, in collaboration with the CRA, that the RN will re-assess the situation daily for the first week, and will teach both the wife (CRA) and the UAP about the client s condition and needs. The collaborative goal between the CRA and the RN is to increase the CRA s knowledge base regarding all ADL and HMA needs so that if UAPs turnover, the wife will have the knowledge base to direct care for her husband, and more tasks may be exempted from delegation in the future. Notes: 4

5 CLIENT C: The client is a 4 y/o female who has Cerbral Palsy (CP), and is not cognitively competent to make health decisions. The client lives in-home with her father who cares for her at night, but he works 5-days/week in a city 2 hours away by car. The father is very knowledgeable about care needs and is able to train the UAP if necessary, and to direct the UAP telephonically. Among other tasks that are delegated/exempted under Rule 225, the client is I&O cathed 4x/day. She has just returned from week at a CP camp and was diagnosed to have a urinary tract infection(uti) (an acute condition). The client is now on antibiotics for this infection, and is afebrile. The UAP is new to this client, but has 2 years of home care experience. This UAP has done I&O catheterizations on females in the past, and she is able to demonstrate this procedure correctly to the nurse. Decision: Score = (out of 25 possible). (Note: the RN must utilize both Rules 224 and 225 for this example; Use Grid Scoring for Tasks Related to Rule 225 only, CANNOT use grid for acute conditions). The RN, utilizing Rule 224 (for the acute condition), determines it is safe to delegate the task of I &O catheterization [224.6(6), competency verification, 224.7()(A-D), Supervision, and 224.8(b)(2)(C), discretionary delegated tasks]. Once the infection is resolved and the UAP is more experienced, the RN, in collaboration with the father (CRA), may elect to exempt this task [which is defined as a HMA in 225.4(8)(B)] from delegation on re-assessment. For other ADL s and HMA s not related to the UTI, the RN may decide to continue to exempt these tasks from delegation (using Rule 225) based on discussion with father (CRA). For the time being, the RN plans to make weekly visits to assess the acute (UTI) condition and the client s response to medications/treatments. Remember that for exemption of tasks from delegation, Rule 225 does not require the RN to assess the UAP s skills/knowledge if there are no acute conditions involved (and the client is in an independent living environment). Notes: 5

6 CLIENT D: This client is a 36 y/o male who is quadraplegic and wheel-chair bound since a MVA at the age of 9. The client works in a bank, and is able to drive himself there with the use of a van that has been adapted for his physical disabilities. This client is able to self-direct as well as to direct any unlicensed person in performing personal care tasks that the client is unable to do for himself. The client is able to feed himself and do oral care/grooming through the use of adaptive equipment. Due to lack of fine-motor movement in his hands/fingers, he requires assistance with bathing, elimination, dressing, medication administration, and other daily activities that are physically beyond his abilities. Having utilized UAPs for assistance since his accident 7 years ago, he is well-versed in directing UAPs to assist with his ADL and HMA needs. Decision: Score = 6 (out of 25 possible). The RN determines it is safe to exempt current ADL and HMA needs based on stability/predictability of client s condition and on client s cognitive ability to direct care provided by UAPs. RN does not need to assess ability of UAP. Notes: 6

7 Rule 225: RN Delegation & Tasks Not Requiring RN Delegation in Independent Living Environments with Stable & Predictable Condition Professional Nursing Assessment Grid Case Examples Instructions: Choose the description that most closely matches the RN assessment of the criteria [Rule 225.6(b)]. Place the corresponding score (numbers -4 or 5) in the grid for that client. Add all scores vertically to arrive at a total score for a given client. There are a total of 25 points possible. Assessment Criteria Assessment Findings *CRA= s Responsible Adult A B C D Ability of client or CRA* to participate in health care decisions and to direct and manage the performance of the task ) with high cognitive functioning or CRA very willing & able to be involved in care decisions 2) with moderate cognitive functioning or CRA only willing and able to assist with certain aspects of care decisions 3) with low cognitive functioning or CRA s ability or willingness to assist with care decisions limited 4) is comatose or cognitively incompetent, or CRA never willing or unable to help with care decisions [if both client and CRA unable to participate, cannot delegate under Rule 225 and must use Rule 224, see Rule 225.(a)(2)] 2 Adequacy/ reliability of support systems available to client or CRA ) Family/friends/other always available if needed & able to assist with care 2) Family/friends/other available approximately 50% of the time or ability to assist is limited 3) Family/friends/other available on occasion, but not on a regular/predictable basis; or ability to assist minimal for whatever reason 4) No support system of any kind available 4 3 Degree of stability and predictability of client s health status relative to the task(s) to be delegated or exempted s condition relative to task to be performed by unlicensed person is: ) Extremely stable and predictable 2) Stable and predictable 90% of time 3) Stable and predictable 75% of the time 4) Rarely (<25%) stable & predictable 5) Never stable and predictable [then cannot delegate under Rule 225 and must use Rule 224, see Rule 225.(a)(3)] 2 7

8 Knowledge base of client or CRA regarding client s health status ) /CRA: Very knowledgeable about health and disease processes impacting client, and can direct UAP for all tasks. 2) /CRA: Knowledgeable to direct care on most of client s tasks. 3) /CRA: Limited knowledge of how to direct tasks. 4) /CRA: No knowledge of client s condition and/or tasks to be performed (cannot exempt ADLs/HMAs from delegation if neither the client nor the CRA has this knowledge base) 3 Ability of client or CRA to communicate in traditional or non-traditional methods ) No language barriers 2) Either UAP or client/cra has limited command of English, or client has mild aphasia, has mentally retardation, etc. 3) Communication factors create a significant barrier but both UAP & client/cra willing and able to work on adapting to situation 4) Profound communication barriers (no common language, severe cognitive impairment or total aphasia, etc.) CRA: : 2 Total=.5 **How frequently will the client s status be re-assessed? ) Re-assess between 6 months- year 2) Re-assess every 90 days 3) Re-assess monthly or bi-monthly 4) Re-assess every week or more often Total Score Score each criteria by its corresponding number; ie: high cognitive function =, comatose = 4 **Regulations for specific settings may dictate re-assessment time frames that differ from this example. Adapt the assessment finding definitions to correlate with the applicable regulations. Suggestions for Use: A low overall score would indicate that the activity/task could be safely delegated or exempted (not requiring delegation). A mid-range score would caution against exemption, but based on RN judgment and assessment, might be safe to delegate. A high score would caution against exemption and delegation, but strength in some criteria could off-set weaknesses in other criteria. For example, delegation with increased supervision or a highly-experienced and competent UAP may make the RN s decision to delegate safe and prudent. Remember: Nursing Tasks cannot be exempted from delegation. 8